Nasogastric Tube (NGT) insertion and removal

Nasogastric tube (NGT) insertion and removal Nursing Procedure

Usually inserted to decompress the stomach , a nasogastric tube (NG) tube prevent vomiting after major surgery . An NG typically is in place for 48-72 hours after surgery, by which time peristalsis usually resumes.

The NG tube can also be used to assess and treat:
Upper GI bleeding
Collect gastric contents for analysis
Perform gastric lavage
Aspirate gastric secretions
Administer medications and nutrients

Equipments needed

Equipments needed
Tube (usually #12, #14, #16 or #18 French for a normal adult.

Equipments needed
Towel or linen-saver pad

Equipments needed
Penlight

Equipments needed
1” or 2” hypoallergenic tape or Opsite

Equipments needed
Liquid skin barrier

Equipments needed
Gloves

Equipments needed
Water soluble lubricant

Equipments needed
Cup or glass of water with straw (if appropriate)

Equipments needed
Stethoscope

Equipments needed
Tongue blade

Equipments needed
Catheter-tip or bulb syringe or irrigation set

Equipments needed
Safety pin

Equipments needed
Ordered suction equipment

Equipments needed (optional)
Metal clamp

Ice

Alcohol pad

Warm water
(in the picture is a hot water bag)

Large basin or plastic container

Rubber band

Preparation
To ease insertion, increase a stiff tube’s flexibility by coiling it around your finger for a few seconds or by dipping it into warm water.
Stiffen a limp rubber tube by briefly chilling it in ice.

Procedure
Provide privacy, wash your hands, and put on gloves.

Inserting an NG tube
Explain the procedure to the patient.
Tell her that she may experience some discomfort and that swallowing will ease the tube’s advancement.

Help the patient into high Fowler’s position unless contraindicated.

Stand at the patient’s right side if you’re right-handed or at her left side if you’ left-handed to ease insertion .

Drape the towel or linen-saver pad over the patient’s chest.

To determine how long the NG tube must be to reach the stomach , hold the end of the tube at the tip of the patient’s nose.
Extend the tube to the patient’s earlobe and then down to the xiphoid process.

Mark this distance on the tubing with tape.

To determine which nostril will allow easier access , use a penlight and inspect for a deviated septum or other abnormalities.

Lubricate the first 3” (7.6 cm) of the tube with a water-soluble gel.

Instruct the patient to hold her head straight and upright.

Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patient nostril.

Aim the tube downward and toward the ear closest to the chosen nostril.
Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.

When the tube reaches the nasopharynx, you’ll feel resistance.

Instruct the patient to lower her head slightly to close the trachea and open the esophagus.

Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube wont enter the patient’s mouth.

Unless contraindicated, offer the patient a cup of water with a straw.
Direct her to sip and swallow as you slowly advance the tube.
This helps the tube pass to the esophagus. (If you aren’t using water, ask the patient to swallow.)

Ensuring proper tube placement
Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing.

As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in bronchus and must be removed immediately.

Stop advancing the tube when the tape mark reaches the patient’s nostril.

Attach the catheter-tip or bulb syringe to the tube and try to aspirate stomach contents.

If you don’t obtain stomach contents, position the patient on her left side to move the contents into the stomach’s greater curvature, and aspirate again.

If you still can’t aspirate stomach contents, advance the tube 1” to 2” (2.5 - 5 cm).
Then inject 10cc air into the tube.

At the same time, auscultate for air sounds with your stethoscope placed over the epigastric region.
You should hear a whooshing sound if the tube is patent and properly positioned in the stomach.

If these test don’t confirm proper tube placement, you’ll need X-ray verification.

Example of a CXR showing a misplaced NG tube

Secure the NG tube to the patient’s nose with hypoallergenic tape, (or other designated tube holder).
If the patient’s skin is oily, wipe the bridge of her nose with an alcohol pad and allow to dry.

Apply liquid skin barrier to make the tape more adherent to the skin.

You’ll need about 4” (10 cm) of 1”tape.
Split one end of the tape up the center about 1 ½” (3.8 cm).
Make tabs on the split ends (by folding sticky sides together).

Stick the uncut tape end on the patient’s nose so that the split in the tape starts about ½” (1.3 cm) to 1 ½” from the tip of her nose.

Crisscross the tabbed ends around the tube.
Then apply another piece of tape over the bridge of the nose to secure the tube.

Alternatively, stabilize the tube with Opsite or a prepackaged product that secures and cushions it at the nose.

To reduce discomfort from the weight of the tube, tie a slipknot around the tube with a rubber band, and then secure the rubber band to the patient’s gown with a safety pin, or wrap another piece of tape around the end of the tube and leave a tab.
Then fasten the tape tab to the patient’s gown.

Attach the tube to suction equipment, if ordered, and set the designated suction pressure.

Provide frequent nose and mouth care while the tube is in place.
An NG tube may be inserted or removed at home.

*Confirming NG tube placement
When confirming NG tube placement, never place the tube’s end in a container of water.
If the tube is malpositioned in the trachea, the patient may aspirate water.

*Confirming NG tube placement
Besides, water without bubbles doesn’t confirm proper placement.
Instead, the tube may be coiled in the trachea or the esophagus.

Removing an NG tube
Explain the procedure to the patient and that it may cause some discomfort.

Removing an NG tube
Assess bowel function by auscultating for peristalsis or flatus.

Removing an NG tube
Help the patient into semi-Fowler’s position.
Then drape a towel or linen-saver pad across her chest to protect her from spills.

Removing an NG tube
Put on gloves.
Using a catheter-tip syringe, flush the tube with 10ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.

Removing an NG tube
Untape the tube from the patient’s nose, and then unpin it from her gown.

Please wear gloves!!!

Removing an NG tube
Clamp the tube by folding it in your hand.

Removing an NG tube
Ask the patient to hold her breath to close the epiglottis.
Then withdraw the tube gently and steadily. (when the distal end of the tube reaches the nasopharynx, you can pull it quickly.)

Please wear gloves!!!

Removing an NG tube
Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.

Removing an NG tube
Monitor the patient for signs of GI dysfunction.

Pointers
If the patient has a nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary.

Pointers
First coil the end of the tube around your hand.
This helps curve and direct the tube downward at the phaynx.

Pointers
While advancing the tube.
Observe for signs that it is entered the trachea, such as choking or breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without a cough reflex.

Pointers
If these signs occur, remove the tube immediately.
Allow the patient time to rest; then try to reinsert the tube.

Pointers
After tube placement, vomiting suggest tubal obstruction or incorrect position.
Assess immediately to determine the cause.

Complications of NG intubation
Although nasogastric (NG) intubation is a common procedure, it does carry risk.

Complications of NG intubation (Long-term concerns)
Potential complications of prolonged intubation includes:
Esophagitis
Esophagotracheal fistula
Gastric ulceration
Pulmonary and oral infection
Sinusitis
Skin erosion at the nostril

Complications of NG intubation (Suction reactions)
Additional complications include:
Electrolyte imbalances
Dehydration

Complications of NG intubation (Suction reactions)
Vigorous suction ,ay damage the gastric mucosa and cause significant bleeding, possibly interfering with endoscopic assessment and diagnosis.

Using an NG tube at home
If your patient will have a nasogastric (NG) tube in place at home, find out who will insert the tube.
If he will have a home care nurse, tell him to expect her.

Make a list; check it twice
If the patient or a family member will perform the procedure, you’ll need to provide additional instruction and supervision.

Use this checklist to prepare teaching topics:
How and where to obtain equipment needed for home intubation.
How to insert the tube.

How to verify tube placement by aspirating stomach contents.
How to correct tube misplacement.
How to prepare formula for tube feeding.
How to store formula, if appropriate.

How to administer formula through the tube.
How to remove and dispose of an NG tube.
How to clean and store a reusable NG tube.

How to use the NG tube for gastric decompression, if appropriate.
How to set up and operate suctioning equipment.
How to troubleshoot suctioning equipment.
How to perform mouth care and other hygenic procedures.

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Nasogastric Tube (NGT) insertion and removal

by Louie Ray on Jul 03, 2008

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Nasogastric Tube (NGT) insertion and removal — Presentation Transcript